While there has been a social psychiatric epidemiology which maps the relationship between social variations and mental health, the views of people within different classes about the topic of mental health and social class has, until recently, been a relatively neglected area. As we have outlined above there is an extensive literature which maps and puts forward explanations for differences between groups in the population in terms of mental health status. Traditionally, there has been little interest in how people themselves construed their distress and oppression. However, more recently, there has been a growing interest in the understanding of lay knowledge. One of the arguments for this greater concentration is to augment gaps in professional knowledge about how ordinary people understand their health.
Blaxter (1990) has explored the views that people have about inequalities in health in general.
In relation to mental health, lay people tend to adopt a relative, rather than absolute, view of men- tal health and social causation (Rogers and Pilgrim 1997). People in all social classes tend to view money problems as a central feature of mental well-being – though those from more middle-class backgrounds identify it as being more of a problem for working-class families. Similarly, work stress and stress related to common life events, such as bereavement and birth, were considered by working-class respondents to affect people similarly, albeit in different ways.
Perceptions of lay knowledge about help-seeking are also important. The expectations of patients and prospective patients shape demand for, and use of, formal services. For example, in
34 A SocIology of MenTAl HeAlTH And IllneSS
primary care settings lay people provide accounts of help-seeking about mental health problems which are different from those offered by GPs (Pilgrim et al. 1997). Professionals emphasize diag- nostic categories (like depression) based upon a symptom approach to presenting problems. By con- trast, patients themselves understand their problems within a unique biographical context situated in time and place. These attributions within a life story include factors such as poverty, employment and unemployment, domestic violence and life events (like birth and death in the family).
Blaxter (1997) found that social inequality in health is not a topic that is very prominent in lay presentations, particularly among those who are most likely to be exposed to disadvantaging environments. Blaxter notes the way in which accounts of social identity have the potential to be self-devaluing, through the act of explicitly labelling and acknowledging inequality and poverty.
Resistance to talk of class, in her respondents, was displaced by accounts of individual, private experience. Class was discussed though in more impersonal discussions of health as a wider social or political phenomenon.
Blaxter’s work lends qualified support to the ‘individualization thesis’: demonstrable objective inequalities in health are not reproduced subjectively by the actors they apply to, in the personal accounts given in qualitative research or in focus group discussions. Class identity and health are negotiated in lay talk as participants shift argumentatively back and forth between competing positions, and public and private realms, in the attempt to make sense of health and illness (Bolam et al. 2004).
Discussion
Some disease categories such as ‘schizophrenia’ have been subjected to persuasive critical decon- struction. For example, this diagnosis has been criticized for its lack of aetiological specificity, its lack of predictive validity and its lack of inter-rater reliability (Bentall et al. 1988). It is a ‘dis- junctive’ diagnosis: that is, two patients called ‘schizophrenic’ may have no symptoms in com- mon (Bannister 1968). Some historians of the concept (Boyle 1991) have even demonstrated that the symptom profiles recorded in the late nineteenth century – when Kraepelin and Bleuler con- structed the disease entity, first called ‘dementia praecox’ and then ‘schizophrenia’ – bear little relationship to the first-rank symptoms that psychiatrists currently use in their diagnoses. In other words, the features of patients given the diagnosis of schizophrenia at its conceptual inception were not the same as those with the same label today.
These conceptual problems with ‘schizophrenia’ are raised in this chapter because the diag- nosis has been at the heart of the case for a class gradient in mental health. If the concept of schizophrenia is discredited by the critiques outlined, does this undermine our confidence in social causationist claims from over 60 years of social psychiatric research? Also, we need to be aware, when examining the relationship between social class and mental health, that the concept has itself become increasingly problematized within sociology. With the decline in the centrality of Marxism within social theory and its replacement by a mixture of other currents including feminism and post-structuralism, social class appears less frequently in the literature or is problematized by non- Marxists when discussing social stratification and societal disadvantage. Reflecting this trend, in the first edition of this book in 1993 we provided only a section, not a whole chapter, on the topic. Parker et al. (1995: 46) in their social-constructivist critique of psychopathology raised an important point to consider about reducing class to an individualized variable, which can exclude a discussion of social processes. Moreover, sociological descriptions of social class divisions or groupings (poor/rich, employed/unemployed and so on) do not automatically connote inequality.
Turner (1986) pointed out that terms such as ‘inequality’ or ‘oppression’ require that empirically described social divisions are then understood within an ideological framework of value judge- ments. Conservative political values emphasize individual freedom rather than the minimization of
SocIAl STrATIfIcATIon And MenTAl HeAlTH 35
social divisions. The notion of ‘oppression’ is more likely to be individualized within conservative ideology and not seen as a matter of social justice. (For this reason some conservative libertar- ians might champion the civil liberties of the mad who are constrained by the State.) The notion of
‘exploitation’ is obvious to the left-wing critic of capitalism but to its conservative supporters it is simply and laudably a matter of employers providing work for others. Earlier we also noted how conservative politicians previously showed a preference for the term ‘health variation’ rather than
‘health inequality’.
These tensions highlight a problem as well for radical social constructivists. A critical real- ist paradigm would argue that there is an irreducible materiality to poverty, which is not open to semantic manipulation or various constructions, a point made well by Pilger (1989). Pilger high- lights the thrust of his argument about poverty by citing the humorist Jules Feiffer thus:
I used to think that I was poor. Then they told me that I wasn’t poor, I was needy. Then they told me it was self-defeating to think of myself as needy. I was deprived. Then they told me deprived was a bad image. I was underprivileged. Then they told me under-privileged was over used. I was disadvantaged. I still don’t have a cent but I have a great vocabulary.
(Feiffer, cited in Pilger 1989: 313) This humorous point is used here seriously to indicate that arguments about the relationship between concepts (or ‘constructions’) and reality need to be understood in relation to both psychiatry and sociology. Psychiatry may well confuse the map with territory at times (with dubious diagnoses such as ‘schizophrenia’ or ‘depression’). At the same time, lay people as well as professionals can consistently spot when their contemporary rules of social convention are broken and when others are mad or miserable (see Chapter 3). Similarly, Turner may be correct to argue that social divisions do not automatically connote inequality, but empty pockets and empty bellies are material realities.
Currently there is a split between one type of literature on inequalities in mental health status and another on the inequalities that service contact might perpetuate. However, as we have dis- cussed earlier, there is evidence that service contact brings with it risks that can have a sustained negative impact on mental health or indeed be a path for exploring how to reverse inequalities. A better understanding of the relationship between service contact and its impact on quality of life and psychological distress would illuminate further our understanding of one aspect of the multi- factorial interaction noted earlier.
Apart from the displacement of Marxism as the central discursive focus of class within sociol- ogy, societal changes have brought with them difficulties in thinking simply about the concept and formulating and conducting empirical projects. For example, the traditional use of the Registrar General’s classifications system has become less and less meaningful. Women can no longer be conceptualized as sharing their husband’s class status – not just because this is now ideologically rejected in the wake of feminism but because marriage has declined in popularity (so it fails to capture the range of forms of interdependent cohabitation). Also women, not men, numerically now dominate the labour market.
Moreover, the old pyramid notion of class structure has been found wanting because of its lack of attention to the relevance of cultural capital and other dimensions other than wealth which are central to contemporary stratification (Savage et al. 2013). Thus, the notion of oppression, which was previously associated mainly, or singularly, with low social class within Marxian soci- ology, has been linked to other social groups independent of their class position – women, black people, people with physical disabilities, people with learning difficulties, gay people, older people and, of particular relevance to this book, people with mental health problems.
Given the conceptual problems within both psychiatric epidemiology, discussed earlier, and the contested concept of class within sociology, we can make only very broad confident state- ments about social class and mental health. For example, it is safe to say that poverty contains
36 A SocIology of MenTAl HeAlTH And IllneSS
causal influences which both create and exacerbate mental health problems. We cannot say defini- tively, however, that ‘poverty causes schizophrenia’. We can say that being poorly employed or homeless increases the probability of mental health problem development, although we cannot, with certainty, say that this person has a mental health problem because they are poorly employed or homeless. We can say that the oppression and powerlessness, associated with low social class, disadvantage poor people during mental health service contact (they are more likely to have inter- ventions imposed upon them and be treated with biological treatments than those in a higher class position), but we cannot say that these discriminatory service eventualities are only attributable to social class, because other variables, such as race or gender, might be alternative or coexisting determinants of professional action.
Additionally, evidence changes over time and the picture of class inequalities and mental health fluctuates. Greater awareness of social class differences on the part of professionals may act to change the pattern of class bias. For example, in contrast to earlier evidence, a more recent picture provided by Weich et al. (2007) suggested that there were few socio-economic differences in the allocation of therapies. This suggests the absence of an inverse care law as far as treatment in primary care is concerned. It maybe the greater awareness of social class differences in primary care (discussed above) means that in this health setting at least social class differences are dimin- ishing over time.
However, notwithstanding the matter of access to therapy, the matter of material disad- vantage remains salient. A tacit understanding of the material, psychological and social ‘costs’
of engagement by patients and health professionals still influence decisions to seek and offer help. These costs are proportionally higher in deprived, marginalized and minority communities, where individual resources are limited and the stigma attached to mental ill-health is higher (Lamb et al. 2012).
Questions
1 does poverty cause schizophrenia?
2 Why are richer people mentally healthier than poorer people?
3 discuss the relationship between housing and mental health problems.
4 discuss lay views about mental health and social class.
5 Have changes in sociological interest in social class produced changes in sociological work on mental health and illness?
6 What are the strengths and weaknesses of the concept of ‘social capital’ in understanding mental health status?
For discussion
Think about people you know who have had mental health problems and discuss ways in which their social class background may have affected their lives.